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Network Health WI · 1 month ago

Pharmacist Utilization Management

Brookfield, Wisconsin, United States

Full-time

Hybrid

Mid Level

3+ years exp

Network Health WI is a healthcare organization focused on improving community health, and they are seeking a Pharmacist Utilization Management. This role involves overseeing the pharmacy department's utilization management program and providing clinical support for quality and health management efforts.

Financial ServicesFitnessHealth CareInsurance

Responsibilities

Administrative/Operational Support

Compliance Regulatory

Professional Collaboration Support

Quality Outcomes (including Medicare Stars, NCQA, HEDIS)

Support and administer vendor oversight audits

Participate in case management, disease management and poly-pharmacy for Network Health patients with extraordinary high drug costs

Collaborate with formulary management team in development of utilization management criteria for Plan drug benefits including incorporating rebate optimization, branch logic, automation, and machine learning where appropriate

Assist with operational oversight of Medicare Part D Fraud, Waste & Abuse Program and other government programs

Pharmacy benefit utilization and prior authorization real-time surveillance

Assist in tracking the introduction of generic drugs/biosimilars to the marketplace and develops focused projects/programs to maximize the cost-saving potential of these drugs and reduce costs in specific drug categories of the Plan formulary

Perform retrospective reviews/audits on claims and prior authorizations for appropriateness

Assist Sales, Member Experience, Providers, Brokers, and Community Partners with Pharmacy Benefit questions

Assist in tracking the introduction of new drugs to the marketplace and advises the Pharmacy and Therapeutics (P&T) Committee on formulary decisions

Other duties and responsibilities as assigned